Q-I love playing tennis during the summer months. The problem is that, whenever I begin my spring playing after the winter months, I get bursitis in my shoulder, which often puts me out of action for weeks. My doctor has variously prescribed steroids and ibuprofen for it, and I find that I’m taking drugs for most of the summer. I’d like to get off all drugs and still play tennis. Is there anything that works to sort out the problem and the pain? WM, Yonkers, NY….

A-Bursitis is a painful inflammation of one or more bursae the little sacs that contain synovial fluid and help to smooth the gliding of your muscles, tendons and skin over your bones. If your problem is chronic, it is usually caused by trauma, which causes pressure to one or more joints. The most common cause of bursitis is overuse of the joint, particularly if you are out of shape. Because it usually affects joints, bursitis is often mistaken for arthritis.

But even if your doctor knows what he’s treating, he still will throw the same types of drugs at your bursitis that he would to a patient with arthritis.

Besides analgesics and oral steroids, doctors like to use ultrasound with these types of sports injuries, which is supposed to calm the inflamed area. They also commonly inject either an anaesthetic or a steroid into the area to reduce inflammation.

While all three regimes will help to reduce your inflammation, steroids have a well known list of side effects from bone loss to Cushing’s syndrome as do anaesthetic drugs. The side effects of using sound waves at close range to human cells and tissues is largely unknown, although we do know, from lab studies of ultrasound, that it causes heat and cavitation (bubbling) to unknown long term effects.

Happily, you may not need to resort to drugs. A number of supplements will help to reduce immediate inflammation every bit as effectively as drugs, according to WDDTY panel member Dr Melvyn Werbach, who has researched numerous supplements in depth.

One of the most important supplements to consider is injections of vitamin B12.

One study examined 40 patients given daily injections of 1000 mcg of B12 intramuscularly for 7 to 10 days, followed by three times weekly for two to three weeks, and once or twice weekly for another two to three weeks. All but three of the patients improved, reporting rapid relief of pain often within a few hours. Many had a complete resolution of symptoms within a few days (Indust Med Surg, 1957; 26: 20-2). In this instance, many of the patients had bursitis with calcium deposition and x-rays showed that the deposits had been completely disbursed.

Perhaps less dramatically, vitamin C with bioflavonoids also can help to reduce swelling. In one case report, a 38 year old with bursitis of the knee given vitamin C plus 200 mg of citrus bioflavonoids three times per day showed reduced swelling within a day and almost complete resolution of the lesion in three days (Am J Digest Dis, 1955; 22: 41-5).

Other bioflavonoids like quercetin have also been shown to set in motion a process which produces anti inflammatory prostaglandins (Prostaglandins, 1980; 20: 627-37).

Two months before you begin playing tennis, you may wish to start taking supplements of omega-3 fatty acids (4 g per day in divided doses), which also help to change the body’s balance of prostaglandins and leukotrienes, and so to markedly reduce inflammation (Wien Klin Wochen-schr, 1986; 98: 104-6). In a tiny study of seven subjects, supplementing with fish oils produced a 48 per cent reduction in the inflammatory products of the pathway which releases arachidonic acid (N Engl J Med, 1985; 312: 1217-23). You need to start taking these supplements two months before you begin playing tennis because it takes that length of time for the supplements to have their effect on body chemistry. Whenever you are taking omega-3 supplements, be sure to take vitamin E as well, which can prevent cellular damage through increased cell membrane peroxidation (Clin Res, 1987; 35: A565).

Besides fish oils, omega-6 fatty acids, which are rich in gamma linoleic acid, also can help reduce inflammation (Am J Clin Nutr, 1992; 55: 39-45).

You may also wish to take proteolytic enzymes such as chymotrypsin and trypsin, which break down amino acids, and have been shown to speed up healing in sports injuries. In one double blind study of football players who were randomly given either a concentrated proteolytic enzyme mixture or placebo, the group given the enzymes had fewer injuries taking them out of the game and were able to return to playing sooner than controls. The controls also had more minor injuries than those taking the enzymes (Am Chiropract, October 1981: 32).

In lab studies, oral doses of chymotrypsin have been shown to increase blood levels of the enzyme (J Clin Pharmacol Ther, 1964; 5: 712-15).

Perhaps the best remedy of all may be taking a combination of supplements. In one lab study, proteolytic enzymes, bioflavonoids and vitamin C given together proved to have a broader action than NSAIDs in reducing inflammation (Arzneim Forsch, 1977; 27: 1144-9). Bear in mind, though, that this particular study used rats, and the results of animal studies do not necessarily apply to humans.

Besides vitamins and supplements, a number of botanicals also contain the same substances that help to reduce inflammation. Chief among these is bromelain, a mixture of proteolytic enzymes from the pineapple plant. Numerous reports have shown that bromelain can reduce swelling after sports injury or trauma (J Ethnopharmacol, 1988; 22: 181-203).

Bromelain is mainly thought to work by stimulating the production of the antiinflammatory prostaglandin E1 (Med Hypoth, 1980; 6: 99-104). It’s also been tested in reducing pain and inflammation of surgery.

In one double blind trial of 160 women who’d received a mediolateral episiotomy (a painful version of the perineum incision to ease birth that is rarely used these days) the women given the bromelein suffered less swelling and pain than controls (Obstet Gynecol, 1967; 29: 275-8). Dr Werbach recommends that you take 125-450 mg three times a day on an empty stomach.

Extract of bilberry (Vaccinium myrtillus), which is often used for varicose veins and macular degeneration, can also reduce inflammation. The active ingredient is anthocyanoside; it’s important to get hold of an extract which has been standardised with an anthocyanidin content of 25 per cent. Dr Werbach suggests a dosage between 160 mg and 480 mg per day.

Curcumin, the yellow pigment of the spice turmeric, also makes for a good antiinflammatory at a dosage of 400 to 600 mg three times per day. In one study, it was shown to have an antiinflammatory response similar to that of the NSAID phenylbutazone, but worked better in reducing oedema and tenderness in patients immediately after surgery (Int J Clin Pharmacol Ther Tox, 1986; 24: 651-4).

You could also try using feverfew (Tanacetum parthenium), which also appears to inhibit the synthesis of prostaglandins and other factors involved in inflammation and pain, and has an action not unlike aspirin. Just make sure the type you purchase has a content of 0.40-0.66 per cent of its active ingredient parthenolide.

Finally, liquorice root (Glycyrrhiza glabra) also inhibits prostaglandin synthesis not unlike the mechanism of cortisone. Indeed, one study showed that the effects of prednisolone were heightened through the use of 200 mg of liquorice root (Endocrinol Japan, 1990; 37: 331-41). Dr Werbach warns that you must not take more than 3 g a day of liquorice root for more than six weeks or it may cause water and sodium retention, hypertension and suppression of certain hormones (N Engl J Med, 1991; 325: 1223-7; BMJ, 1977; 1: 488-90). In fact, one patient who consumed liquorice actually suffered cardiac arrest (BMJ, 1977; 2: 738-9).

If you plan to use liquorice as a therapy, it may be prudent to have regular monitoring of blood pressure and electolytes, and to also increase your potassium intake (N Engl J Med, 1991: 325: 1223-7).

To avoid future bouts of bursitis, it is first of all important for you not to just exercise in the summer. Most sports injuries occur because the patient is in poor physical condition, has bad posture, or moves one or more limbs in an awkward position. If you can manage to engage in some moderate exercise all year long, you won’t have this annual trial of fire when launching your summer tennis programme.

Another area to look at is your posture. Poor posture can result in bursitis. You may wish to investigate Alexander Technique or a good osteopath or chiropractor, who can check that you are in alignment.

Make sure to eat plenty of cold water fish, such as salmon, herring, mackerel, tuna and bluefish, which contain plenty of omega-3 fatty acids.

You should also have your mineral levels checked. Inadequate levels of zinc and copper can cause reduced superoxide dismutase enzyme activity, leading to accumulation of the superoxide radical, which can contribute to the development of inflammatory diseases (Prog Med Chem, 1989; vol 26).

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